ETHNIC/RACIAL PROFILE OF STUDENT POPULATION IN SCHOOLS WITH

Assembly on School-Based NASBHCNational Health Care Bringing Health Care to Schools for Student Success School-Based Health Centers National Census School Year 2004-05 PURPOSE A. Hanson 2007 The National Assembly on School-Based Health Care conducted the 2004-05 Census, the tenth count of school-based health centers (SBHCs) since 1986, to: Provide a better understanding of the role of SBHCs in meeting the needs of underserved children and adolescents, Collect up-to-date data on demographics, staffing services, operations, prevention activities, clinical policies and trends, and Create a national directory of programs. LOCATION OF SBHC (n=1234) Census 2004-05 identified 1709 school-connected programs nationwide. This number includes school-based, mobile and linked programs. 1335 or 78% of known programs responded to the survey. These data on practices and operations during the 2004-05 school year were collected from October 2005 through October 2006. Efforts were made to confirm that non-respondents were open during the 2004-05 school year. This report describes the 1235 sites providing a minimum of primary care service, defined as having a staffing profile with a nurse practitioner, physician assistant or physician on school grounds. Programs not providing primary care services on school grounds are not presented in this report. In School Building 87% On School Property 11% Mobile (non-fixed) 2% SCHOOLS (n=1222) Settings for SBHCs are as varied as the types of schools in the United States. As schools nationwide re-design for students academic success, SBHCs adapt to meet the age-appropriate needs of the students they are serving. 80% of the programs report serving at least one grade of adolescents. 41% are designated as Title One schools. 6% of SBHCs are in alternative schools. 41% of SBHCs are in schools with more than 1000 students. High 30% Elementary 20% Middle 15% Elementary/Middle 14% K-12 14% Middle/High 7% ETHNIC/RACIAL PROFILE OF STUDENT POPULATION IN SCHOOLS WITH SBHCs (n=1235) Students in schools with SBHCs are predominantly minority and ethnic populations that have historically experienced health care access disparities. 69% of SBHCs report that more than half of their student population is eligible for the United States Department of Agriculture s National School Lunch Program, which provides free and reduced lunch a marker for underserved students. Hispanic 34% Black 30% White 30% Asian 4% Native American 1% Other 1%

SBHCs BY COMMUNITY CHARACTERISTIC (n=1235) SBHCs are located in geographically diverse communities, with the majority (59%) in urban communities. Nearly one in three health centers is in rural schools. Sponsorship of SBHCs is most typically by a local health care organization, such as a hospital (29%), community health center (22%), and health department (17%). Other community partners include nonprofit organizations, universities and mental health agencies. Only 14% are sponsored by the school system. SBHC PARTNERSHIPS: SCHOOL NURSES School nurses and SBHCs (where they are both present) relate to each other in one of two ways: they either maintain separate facilities or co-locate within the same health suite. Some SBHCs partner with the school to serve children with special health care needs: 30% monitor medications; 24% serve on Individualized Education Program teams; 22% are involved in developing individual health plans; and 20% review medication recommendations. Other SBHC partnerships (non-sponsor) that contribute staff or in-kind services include school system (67%), local health departments (39%), hospitals (35%), state health departments (29%), mental health agencies (28%), universities (27%), and substance abuse agencies (13%). Rural Suburban Co-located within SBHC Present but separate Urban School nurse not present in school SBHC STAFFING MODELS (n=1235) Primary Care Mental Health PLUS Unknown Primary Care Mental Health Primary Care Only Staffing patterns in America s SBHCs can range from an on-site provider in a school four hours a week to six full-time equivalents. These come from multiple disciplines operating in a center that is open more than 40 hours each week. While there are many health care staffing configurations within SBHCs, the presence of primary care providers in any combination of physician, nurse practitioner or physician assistant is the common denominator. Three SBHC staffing patterns described here illustrate different approaches to school-based health care. PRIMARY CARE The chief characteristic of this staffing model is what it doesn t have: a mental health professional. The primary care SBHC staff is typically comprised of a nurse practitioner or physician assistant with medical supervision by a physician. Clinical support is provided by a registered or licensed practical nurse with assistance from a medical clerk or health aide. In a small percentage of these SBHCs, staff may be augmented by social service, health education, or dental professionals. SBHC Staff and Mean Hours (Hrs)/Week by Model % of All Primary Care PC-MH PC-MH+ PROVIDER TYPE N SBHCs Hours Hours Hours Primary Care 1235 100 26 26 33 Mental Health 805 65 0 29 36 Nursing/Clinical Support 1071 87 44 55 59 Dental 153 12 24 0 25 Health Education 186 15 11 0 24 Nutrition 163 13 11 0 25 PRIMARY CARE - Mental Heath The largest group of SBHCs is staffed by primary care providers in partnership with a mental health professional whether licensed clinical social worker, psychologist, or substance abuse counselor. Clinical and administrative support is similar to the primary care model. PRIMARY CARE - Mental Health PLUS The third model is the most comprehensive. Primary care and mental health staff are joined by other disciplines to complement the health care team. The most common addition is a health educator, followed by social services case manager, and nutritionist.

PRIMARY CARE SERVICES PROVIDED BY SBHCs (n=1176-1259) The majority of SBHCs provide the basic tools of primary preventive care. The most common components in the SBHC scope of service are comprehensive health assessments, anticipatory guidance, vision and hearing screenings, immunizations, treatment of acute illness, laboratory services, and prescription services. Dental Comprehensive Care Dental Preventive Care Care for Infants of Students Dental Screenings/Diagnostics Medications Dispensed to be Taken at Home Assessment of Psychological Development Standardized Behavioral Risk Assessment Lab Tests Immunizations Treatment of Chronic Illness Medications Administered in the Center Nutrition Counseling Sports Physicals Asthma Treatment Anticipatory Guidance Prescriptions for Medicines Screenings Comprehensive Health Assessments Treatment of Acute Illness 9% 22% 36% 42% 61% 71% 84% 86% 90% 90% 94% 96% 97% REPRODUCTIVE HEALTH SERVICES OFFERED TO ADOLESCENTS ON SITE (n=897-931) Health centers serving middle and high school aged students (n= 977) are more likely to offer abstinence counseling (76%) and provide on-site treatment for sexually transmitted diseases (62%), HIV/AIDS counseling (64%), and diagnostic services such as pregnancy testing (78%). Family planning services most often encompass birth control counseling (65%) and follow up (48%). A minority of health centers neither provide on-site nor refer to an off-site provider for any reproductive health services. Prenatal Care Pap Smears HIV Testing Follow-up of Contraceptive Users Urine Based Chlamydia Screening Sexual Orientation Counseling Gyn Exams Chlamydia Screening STD Diagnosis and Treatment Counseling for Birth Control HIV/AIDS Counseling Abstinence Counseling Pregnancy Testing 12% 42% 44% 48% 54% 53% 57% 61% 62% 65% 64% 76% 78% CONTRACEPTION PROHIBITION (n=853) More than two-thirds of SBHCs are prohibited from dispensing contraception a policy determined most often by the school district. Who Prohibits Dispensing Contraceptives in SBHCs NO YES Other 1% State Policy 2% Don t Know 2% School Policy 5% State Law 9% Health Center 15% School District 66% 0% 10% 20% 30% 40% 50% 60% 70%

PREVENTION, EARLY INTERVENTION, AND RISK REDUCTION Most common prevention, early intervention, and risk reduction activities are provided to students individually through services such as immunizations (89%), vision, hearing, and scoliosis screenings (), and behavioral risk assessment (84%). A significant number of SBHCs are engaged in population-based health promotion in small groups, classrooms, and school-wide on topics including fitness and weight, asthma, dental, parenting, resiliency and social skills building, mental health promotion, as well as tobacco, alcohol and drug, violence, injury, pregnancy (abstinence and comprehensive), and STD/HIV prevention. Selected Prevention, Early Intervention, and Risk Reduction Activities Offered by SBHCs Mental Health Promotion Classroom Tobacco Prevention/Cessation Schoolwide STD/HIV Prevention Classroom Violence/Conflict Resolution Small Group Resiliency/Social Skills Building Small Group Asthma Small Group Fitness/Weight Small Group 35% 37% 38% 42% 47% 52% 56% MENTAL HEALTH SERVICES IN SBHCs WITH (n=805) AND WITHOUT (n=388) MENTAL HEALTH PROVIDERS SBHCs offer a variety of on-site mental health and counseling services through several modalities, including individual, one-on-one counseling, student group counseling, family therapy, consultation, and case management. These services are more likely to be provided when mental health professionals are included as center staff, although these services are also delivered by primary care staff. Those services most frequently reported as provided by centers without mental health professionals on staff include referrals (63%), mental health diagnosis (63%), and screening (62%). Predominant MH Provider is Licensed Counselor/SW/Therapist (n=656 or 81% of programs with a mental health provider). Twelve percent (n=93) of SBHCs report having a drug and alcohol counselor on-site. Ten percent (n=77) reports having psychiatrist on-site. Medication Management/Administration With MH Staff Without MH Provider P<.01 Long Term Therapy Psycho-education Case Management Substance Use Counseling Brief Therapy Tobacco Use Counseling Conflict Resolution/Mediation Skill-Building Screening Referrals Assessment Crisis Intervention Grief and Loss Therapy Mental Health Diagnosis 54% 34% 62% 13% 70% 23% 73% 29% 77% 37% 80% 34% 82% 46% 87% 36% 88% 32% 89% 62% 63% 52% 53% 39% 63%

OTHER POPULATIONS SERVED BY SBHCs (n=1227) Although the school population is the SBHC s primary target, many (55%) provide services to patients other than enrolled students: students from other schools in the community (33%); family members of students (29%); faculty and school personnel (19%); out-of-school youth (16%); and other community members (12%). Other people from the community - 12% Out-of-school youth - 16% Faculty/school personnel - 19% Family of student users - 29% Students from other schools - 33% Only children in the school - 45% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% PATIENT REVENUE AS % OF TOTAL SBHC BUDGET Most SBHCs bill third-party payers for health center visits, including Medicaid (72%), private insurance (50%), and the State Children s Health Insurance Program (45%). Twenty percent bill students or families directly. Two in three SBHCs report that patient revenue comprises less than 25% of their total budget, and only 8% report greater than 50% of their total budget. (n=845) Non revenue funding sources including government entities are: State Government - 72% Private Foundations - 62% County/City Government - 42% Corporations/Business - 38%* *Section 330 Public Health Service Act funding accounts for great majority of fed government source. LENGTH OF TIME SBHC HAS BEEN OPEN (n=1157) 67% of the nation s SBHCs are five years or older, up from 41% in 1998. 152 new centers opened since the 2001-02 census. Compared to 1998 and 2001, the cohort of new SBHCs (< 2 years) indicates less growth. Six percent reported that in the history of its operation the SBHC closed and re-opened its doors at least once. 1998-99 (n=755) 2001-02 (n=1112) 2004-05 (n=1157) < 2 YRS 2-4 YRS 5-9 YRS 10 YRS OR > 17 42 21 20 8 21 45 26 4 20 20 47 SBHC HOURS OF OPERATION (n=1221) The majority of SBHCs are open during normal school hours, and typically more than 30 hours per week. Some health centers provide expanded hours enabling students to make visits during out-of-school time, including after school (61%), before school (48%), and during the summer (35%). A small cohort of SBHCs are only open before and after school. 65% of SBHCs report having a pre-arranged source of after-hours care. 31 Hours Health Center is Open... or More 0-8 Hours Weekend 1% Summer 35% 9-30 Hours Before School 48% After School 61% During School 97% PARENT ENGAGEMENT Parent involvement in SBHCs most often occurs during enrollment when parental consent is required before the child receives the full range of services offered by the program. Some SBHCs allow parents to restrict their child s access to specific services. A minority of health centers engage parents directly in center governance, operations, and activities. Parent Can Restrict Access to Specific Health Services Advisory Board Member Advocacy Activities Organizing Center Events Parent Engagement in SBHCs 35% 39% 41% 58%

SCHOOL-BASED, MOBILE, AND LINKED HEALTH CENTERS - School Year 2004-05 (n=1227) Alabama 9 Alaska 2 Arizona 91 California 140 Colorado 36 Connecticut 73 Delaware 26 District of Columbia 5 Florida 123 Georgia 3 Illinois 53 Indiana 88 Iowa 15 Kansas 3 Kentucky 15 Louisiana 56 Maine 27 Maryland 64 Massachusetts 57 Michigan 69 Minnesota 21 Mississippi 36 Missouri 3 Nevada 3 New Hampshire 1 New Jersey 82 New Mexico 42 New York 195 North Carolina 51 Ohio 26 Oklahoma 8 Oregon 45 Pennsylvania 23 Puerto Rico 2 Rhode Island 7 South Carolina 11 South Dakota 4 Tennessee 19 Texas 72 Utah 4 Vermont 5 Virginia 18 Washington 18 West Virginia 41 Wisconsin 16 TOTAL 1708 For a complete view of the census results, view our Web site at www.nasbhc.org OUR MISSION NASBHC represents those who support, receive, and provide health care to approximately 1700 schools and school-connected programs across America. We advocate for national and state policies, programs, and funding that sustain, grow, and integrate school-based health care into our nation s health care and education systems to promote greater academic success. We provide leadership, resources, and technical assistance to enable school-based health centers to deliver high quality services, become financially stable, and play an active role in public policy. The national census is conducted by the National Assembly on School-Based Health Care. This report was prepared by Linda Juszczak, John Schlitt, and Aisha Moore, May 2007. We gratefully acknowledge the support of the census advisors Leslie Mandel, Mona Mansour, Jan Marquard, Bob Nystrom, and Mayris Webber as well as the school-based health center professionals who generously provided data for their programs. This report honors the work they do each day. Funding for the 2004-05 census was provided by the Health Resources and Services Administration s Maternal and Child Health Bureau, Office of Adolescent Health and Bureau of Primary Health Care,Office of Special Populations, and the WK Kellogg Foundation. 666 11th Street, NW Suite 735 Washington, DC 20001 888.286.8727 Assembly on School-Based NASBHCNational Health Care Bringing Health Care to Schools for Student Success